1. Code patient:

1. ________

2. Contacts: 1. Yes 2. No

Cell/Telephone Number_________________ E-mail____________________

2. ________

3. Age (years): 1. <20 years 2. ≥20 years

3. ________

4. Place of origin: 1. Capital City (Ceará/BRAZIL) 2. Countryside

4. ________

5. Marital status: 1. Casada/união consensualMarried/Live with partner 2. SolteiraSingle

5. ________

6. Occupation: 1. Works 2. Does not work

6. ________

7. Education (Completed schooling years): 1. ≤9 years 2. >9 years

7. ________